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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530193
Report Date: 08/22/2024
Date Signed: 08/22/2024 10:20:18 AM

Document Has Been Signed on 08/22/2024 10:20 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TIERRA RESIDENTIALFACILITY NUMBER:
365530193
ADMINISTRATOR/
DIRECTOR:		ROJAS, DIANAFACILITY TYPE:
735
ADDRESS:12445 TIERRA BONITA DRIVETELEPHONE:
(909) 455-8159
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 0DATE:
08/22/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Diana Rojas-LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPAs) Michelle Echeverria and Lavette Farlow conducted an announced visit to complete the Pre-licensing inspection. LPAs met with Licensee, Diana Rojas. The fire clearance was approved on 5/03/2024 for four (4) nonambulatory clients.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining area, living room, laundry room, backyard with shed, and attached garage. LPAs toured the interior and exterior areas of the facility. The following were inspected:

Client Bedrooms: All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, nightstands, dressers, chairs, and lighting.

Client Bathrooms: The bathroom appliances were operating in safe and sanitary condition.

Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter top were free of debris and in good repair. There was a locked and secured cabinet where medication and sharps will be stored. There was also non-perishable food inside the pantry and perishable food inside the refrigerator/freezer. There is a safely locked and secured filing cabinet where clients and staff files are going to be stored. Stove and water temperature were not tested due to licensee stating that the water heater was not turning on since it was turned off when the stove got replaced. LPAs observed the fireplace not securely enclosed and accessible to clients.

Common Sitting Areas: There is adequate seating in the common areas. The facility has a supply of activities for the clients.

Laundry Room/ Garage: The laundry room is near the entry to the garage.



Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies were available.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: TIERRA RESIDENTIAL
FACILITY NUMBER: 365530193
VISIT DATE: 08/22/2024
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Backyard: There is one shed used for storage and no bodies of water in the backyard. There are two shaded areas with one table and chairs for the clients. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There was one (1) charged fire extinguisher in the facility. LPAs observed operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and ammunition.

Postings: LPAs observed missing required postings including the visitation policies, emergency/disaster plans, complaint procedures, and personal rights.

First aid and telephone: The facility was equipped with a complete first aid kit and emergency kits. The facility has a functioning land line and telephone for clients use.

Pre-Licensing is incomplete and the following deficiencies require to be resolved by 08/26/2024:

Enclose the fireplace and make it inaccessible to clients.


Print and post the required postings in a common area.
Fix water heater so that the stove functions and the hot water temperature meets the regulations.

An exit interview was conducted, and this report was discussed and provided to Licensee, Diana Rojas.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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